胃癌的广泛性淋巴结清除术10年经验总结

目的　研究广泛性淋巴结清除术对胃癌患者的预后、手术并发症和死亡率的影响。方法　对1989年1月至1999年1月10年间的782例胃癌手术患者进行回顾性分析。结果　本组并发症发生率为11 6%,其中D0 D1、D2、D3 D 3 术后并发症发生率分别为9 4%、10 8%、14 5%,三者之间比较 P>0 05;手术死亡率为 4 1%,其中 D0 D1、D2 和 D3 D 3 的手术死亡率依次为 4 3%、3 0%、4 6%,三者之间比较 P>0 05。总体5年生存率为38 7%,其中姑息性切除组为5 3%,根治性切除组为49 9%。D0 D1、D2 和D3 D 3 手术的5年生存率分别为30 4%、59 9%和31 8%,其中Ⅲ期患者的5年生存率分别为D242 3%,D3 D 3 59 2%,P<0 05。结论　胃癌的广泛性淋巴结清除术是安全的,能够显著地改善Ⅲ期胃癌患者的预后。     

Extended lymphadenectomy is associated with a survival benefit for node-negative gastric cancer

The purpose of this study was to determine whether extended lymph node (D2) dissection is associated with a survival benefit for patients with histologically node-negative gastric cancer at a single institution in the United States. Review of the prospective gastric database at Memorial Sloan-Kettering Cancer Center from July 1985 to August 1995 identified 774 patients who had undergone curative gastric resection. Of these, 247 patients (32 %) were identified with histologically negative lymph nodes by hematoxylin-eosin staining. Data are expressed as median (range). Overall survival was compared by log-rank test. The overall 5-year survival rate for the entire cohort was 79%. The extent of lymph node dissection did not predict survival over the entire cohort. However, when stratified for tumor (T) stage, D2 dissection offered a survival advantage for T3 tumors. The 5-year survival rate for patients with T3 tumors undergoing a D2 dissection (n = 15) was 54% compared to 39% for those undergoing a DI dissection (n = 53, P < 0.05). D2 dissection is associated with improved survival in advanced T stage, node-negative gastric cancer. With adequate staging, results of gastric resection for adenocarcinoma in Western countries begin to approximate those seen in Japan. Excision of N2 lymph nodes may also remove microscopic metastatic disease, contributing to the survival benefit. Supported by the Lillian Wells Foundation. Presented at the Thirty-Eighth Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington, D.C., May 11–14, 1997.     

Extended lymphadenectomy in gastric cancer: when, for whom and why.

Although lymph node metastasis is a major prognostic factor in gastric cancer, the optimal extent of lymph node dissection still remains a subject of debate. The influence of extended D2 lymphadenectomy on morbidity and long-term survival is controversial. Reports from many Japanese and some Western institutions show similar morbidity and mortality rates for both limited D1 and extended D2 resections. However, the four available randomised trials show a significant increase in operative morbidity and mortality after a D2 resection. The authors of these trials believe that distal pancreaticosplenectomy is responsible for this increased morbidity and mortality and not the lymphadenectomy itself. Retrospective and prospective non-randomised studies show superior stage (II/IIIA) specific survival rates after D2 resections. However, these studies did not eliminate stage migration and randomised trials failed to show any survival advantage in favour of the D2 resection. Current data suggest that D2 resection is beneficial to the subgroup of patients with N1 or N2 disease undergoing potentially curative resection. However, Western studies that support D2 resection, fail to show any survival advantage for D2 resection in N2 patients, reporting a benefit only to N0 or N1 patients. In contrast, Japanese series report a large number of N2 long-term survivors. The question as to the possible beneficial effect of extended lymphadenectomy in gastric cancer is difficult and complex. D2 resection increases the potentially curative resection rate, at least in N2 patients, achieves a better locoregional tumour control and provides the only chance for cure among N2 patients since adjuvant treatment in gastric carcinoma has not yet been proved effective. However, all randomised comparisons warn of an increased risk after D2 resection. By avoiding pancreaticosplenectomy, however, the morbidity can be within acceptable limits. D2 gastrectomy seems to be the most attractive procedure in the surgical management of gastric cancer.     

Extended (D2) lymphadenectomy in gastric cancer: a five year experience

The extent of lymph node dissection in stomach adenocarcinoma is currently under debate. Japanese data strongly support the therapeutic value of extended lymphadenectomy (D2 node dissection), whereas in Western countries several prospective trials have recently been completed with contrasting results. During the period May 1993 to May 1998, 164 patients with gastric cancer were observed: 136 patients, treated with a radical surgical procedure including lymph node dissection according to the guidelines of the Japanese Research Society for Gastric Cancer, were eligible for our analysis. Clinical, histopathological, and surgical factors were examined for their influence on long-term survival. Our results on morbidity and mortality rates are similar to Japanese series: we suggest that the experience and training of the surgeon and his personal attitude towards extensive lymph node dissection may, therefore, be a major factor influencing the morbidity associated with the procedure. The relatively high estimated 3-year survival rate (52%) suggests support for extended lymphadenectomy (D2 dissection) in gastric cancer as standard treatment.     

Extended radical lymphadenectomy in patients with urothelial bladder cancer: results of a prospective multicenter study

PURPOSE: Previous studies demonstrate a positive correlation between postoperative survival and the extent of pelvic lymphadenectomies in patients with bladder cancer. However, the distribution of nodal metastases has not been examined in sufficient detail. Therefore, we conducted a comprehensive prospective analysis of lymph node metastases to obtain precise knowledge about the pattern of lymphatic tumor spread. MATERIALS AND METHODS: Between 1999 and 2002 we performed 290 radical cystectomies and extended lymphadenectomies. Cranial border of the lymphadenectomy was the level of the inferior mesenteric artery, lateral border was the genitofemoral nerve and caudal border was the pelvic floor. We made every effort to excise and examine microscopically all lymph nodes from 12 well-defined anatomical locations. RESULTS: Mean total number and standard deviation of lymph nodes removed was 43.1 +/- 16.1. Nodal metastases were present in 27.9% of patients. The percentage of metastases at different sites ranged from 14.1% (right obturator nodes) to 2.9% (right paracaval nodes above the aortic bifurcation). By studying cases of unilateral primary tumors or with only 1 metastasis we observed a preferred pattern of metastatic spread. However, there were many exceptions to the rule and we did not identify a well-defined sentinel lymph node. CONCLUSIONS: We strongly recommend extended radical lymphadenectomy to all patients undergoing radical cystectomy for bladder cancer to remove all metastatic tumor deposits completely. The operation can be conducted in routine clinical practice and our data may serve as a guideline for future standardization and quality control of the procedure.     

Extended pelvic lymphadenectomy for prostatic cancer.

Thirty patients with clinically localized prostatic carcinoma underwent extended pelvic lymph-adenectomy, including the presacral and presciatic (lateral sacral) areas. The first echelon of pelvic nodes to be involved by metastases was the external iliac, obturator, presacral and presciatic. The deep presacral-presciatic nodes were involved almost as often as the more superficial external iliac-obturator group. Metastases limited only to the deep pelvic nodes were found in 14 per cent of the cases.     

Extended lymphadenectomy in stomach cancer]

The results of surgical treatment in 120 patients with cancer of the stomach have been analyzed. Metastatic involvement in all groups of lymphatic nodes was revealed in 68.3% cases, retroperitoneal metastases were detected in 46 patients (38.3%). 38 subtotal resections of the stomach and 82 gastrectomies with retroperitoneal lymphadenectomy R2 and R3 were performed. Esophagojejunoanastomosis end-to-end with a loop excluded by Roux was applied in 110 patients and esophagoduodenoanastomosis--in 10 patients. Insufficiency of esophagointestinal anastomosis was revealed in 3 patients. The rate of complications was 29.2%, lethality--8.3%. High rate of postoperative complications and lethality were explained by initially severe conditions of the patients (61%) and by complicated forms of gastric cancer in 6 patients. Improvement of early results of surgical interventions lies in the usage of antibacterial prophylaxis, preventive intravenous introductions of 5-fluorouracil, adequate drainage of the abdominal cavity, careful preparation and ligation in the course of the operation.     

Strategy for lymphadenectomy of gastric cancer

To determine the extent of lymphadenectomy necessary to cure early gastric cancer, the relationship between the frequency of nodal involvements and the extent of the primary invasion was examined in 274 patients with primary cancer of the stomach. We also evaluated the relationship between the number of metastatic lymph nodes, the pattern of metastases to the nodes, and the histologic type of the primary tumor. In early gastric cancer, lymph node metastasis was more frequent in protruded-type cancer with invasion into the submucosa more than 3 cm in diameter and located in the lower third of the stomach, but was limited to the group 1 lymph nodes, which were defined as being anatomically located nearest to the cancer. In cancer invading into the muscularis propria, metastasis to the group 2 or 3 lymph nodes, which were defined as being anatomically located farther from the cancer than group 1, was found. The number of lymph nodes involved and extent of cancer metastasis in these lymph nodes metastasis, differentiated early gastric cancer had more lymph node involvement and wider extent of metastases than undifferentiated cancers. The cancer cells sometimes replaced most of the node and invaded the perinodal fatty tissue, even in early gastric cancer. In addition, it is occasionally difficult to distinguish macroscopically early gastric cancer with submucosal invasion from cancer invaded into the muscle layer. In conclusion, group 1 and 2 lymph nodes, including perinodal fatty tissue, should be removed completely, even in early gastric cancer, except for carcinoma in situ, particularly when the cancer is of the differentiated type.     

基层医院腹腔镜辅助远端胃癌根治术治疗进展期胃癌

目的: 探讨基层医院行腹腔镜辅助远端胃癌D2根治术治疗进展期胃癌的可行性,并与开腹手术作比较。方法: 从我院2016年1月至2018年3月期间的进展期胃癌病人中选取合适的研究对象,腹腔镜组与开腹组各40例,回顾性分析近期临床疗效。结果: 腹腔镜组的手术时间、出血量以及术后排气恢复时间、术后下床活动时间、术后进食时间分别为（183.71±16.08） min、（64.02±10.69） mL、（3.08±0.61） d、（2.88±0.70） d、（3.10±0.71） d,与开腹组比较,均具有统计学差异（P<0.05）。腹腔镜组术后的淋巴结清扫数和术后病理检查中肿瘤距远、近切缘的距离分别是(30.70±8.84)枚、（4.73±1.16） cm、（7.10±1.14） cm,与开腹组的差异均无统计学意义（P>0.05）。开腹组切口感染和肺部感染的发生率高于腹腔镜组(P<0.05),但两组吻合口出血、吻合口漏及胃动力障碍的发生率无统计学差异（P>0.05）。结论: 腹腔镜辅助手术出血少、恢复快,具有与开腹手术相似的治疗效果。     

胃癌规范化淋巴结清扫治疗的价值

目前世界范围内，胃癌的总体死亡率仅次于肺癌居第二位。外科手术是唯一有希望治愈胃癌的方法。随着外科手术技术的发展和围手术期监护、治疗水平的提高，胃癌的手术切除率和生存率在不断提高。东西方对胃癌根治性手术时进行淋巴结清扫的必要性目前已基本达成共识。规范开展淋巴结清扫术已成为目前讨论的焦点。本文回顾胃癌外科治疗研究进展，结合自身研究经验，对胃癌规范化淋巴结清扫的价值进行探讨。     

Extended lymphadenectomy improvement of overall survival of gastric cancer patients with perigastric node metastasis

Background  

The superiority of extended lymphadenectomy for the prognosis of gastric cancer (GC) is still controversial. The authors hypothesized that extended lymphadenectomy could improve the overall survival (OS) of GC patients with a specific extent of lymph node metastasis.     

试析腹腔镜胃癌根治术淋巴结清扫的相关问题

手术是胃癌治疗的基石,但关于淋巴结清扫的范围东西方学者一度有过争论。基于2010年Dunch研究15年随访结果,D2淋巴结清扫作为进展期胃癌治疗的标准术式方得到普遍认同。至此也为胃癌腹腔镜淋巴结清扫术的应用奠定基础,开启了胃癌外科治疗的新纪元。自从1994年日本Kitano教授进行了首例腹腔镜手术治疗早期胃癌以来,其应用于胃癌的证据越来越多,现已被日本胃癌治疗指南推荐为早期远端胃癌的标准治疗选择。在我国,依据中国胃肠肿瘤外科联盟收集2014年至2016年间3年来自全国73家中心88000余例胃癌手术病例数据来看,接受腔镜手术患者的比例已超过30%,并呈每年上升趋势。由于腹腔镜手术具有微创、视野放大、操作精细、便于沟通、交流及学习等特点,其将具有更广阔的应用前景。本文结合笔者团队既往的经验,讨论腹腔镜下胃癌淋巴结清扫的特点。希望借此文对读者有所启发。     

腹腔镜胃癌淋巴结清扫的策略

1994年日本Kitano等首次报道了腹腔镜胃癌根治术治疗早期胃癌，由于其相对于传统的胃癌根治术，具有明显的微创优势，因而在国内外逐步得到开展。目前，腹腔镜胃癌根治术用于早期胃癌治疗的临床报道较多。取得了与开腹手术相当的近远期疗效固，也使腹腔镜胃癌根治术的手术指征从早期胃癌扩大到较早期的进展期胃癌。1997年Goh等首次将腹腔镜胃癌D2根治术用于治疗进展期胃癌，由于该手术包括肿瘤根治切除、扩大淋巴结清扫和消化道重建三个技术环节，手术难度大，特别是腹腔镜下能否达到与开腹手术相当的淋巴结清扫范围和平均淋巴结清扫数量，这是腹腔镜胃癌根治手术开展伊始众多学者疑虑和关注的焦点。     

Indications of a minimized scope of lymphadenectomy for submucosal gastric cancer

Background A recent trend for less invasive surgery has increased consideration for a minimized scope of lymphadenectomy for submucosal cancer; however, feasibility criteria have not been precisely established. Methods Patterns and sites of nodal involvement were retrospectively investigated in 294 patients with solitary submucosal gastric cancer in association with other clinicopathologic characteristics, including pre- and intraoperative evaluations of cancer depth (cT) and nodal involvement (cN). Results Among the early (cT1) and node-negative (cN0) cancer, intestinal (≤1.5 cm) and diffuse types (<-1.0 cm) of submucosal cancer showed low incidences of nodal involvement (3%) confined to the first tier. When the cancer exceeded these cutoff diameters, positive nodes of the second tier were confined to three priority stations (left gastric, common hepatic, and celiac arteries) at an incidence of 2.3%. Perigastric and preferential dissection of these three node stations (modified D2 dissection) showed survival benefits identical to those of a conventional D2 dissection. Conclusions When submucosal cancer is evaluated as cT1cN0, a virtually sufficient minimized scope of lymphadenectomy is a D1 dissection for that within the cutoff diameter and a modified D2 dissection for that exceeding the cutoff diameter. These two types of dissection can even cover the infrequently observed node-positive stations and can realize no residual disease at surgery.     

The role of lymphadenectomy in curative surgery for gastric cancer

A total of 530 cases of gastric cancer treated by curative surgery was analyzed with regard to lymph node metastases and survival rate. During this period, curative resections made up 75.9% of all resections (530/698) for gastric cancer, and the 5-year survival rate was 50.6% (268/530). A total of 15,739 regional lymph nodes (an average of 30 per specimen) removed at surgery were examined histologically for metastases, and 16.0% were found to be positive. Of 339 patients with advanced, transmural cancers, 74.9% had lymph node métastases; those with negative nodes had a 5-year survival rate of 63.5%, while those with positive nodes had a 5-year survival rate of 29.9%. The 5-year survivors with positive nodes made up 58.5% of all 5-year survivors. The almost complete removal of at least the primary and secondary lymph node groups draining a gastric neoplasm is an essential part of the curative surgical treatment of gastric cancer. For lesions in the upper and middle portions of the stomach that invade the serosa of the posterior wall, total gastrectomy with a caudal hemipancreatectomy and splenectomy should be aggressively performed, so as to accomplish complete en bloc removal of the lymph nodes in these regions.

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Résumé Nous avons analysé, aux points de vue métastases ganglionnaires et survie, 530 cas de cancers gastriques traités par chirurgie curative. Pendant cette période, les résections à visée curative ont représenté 75.9% de toutes les résections pour cancer gastrique (530/698) et la survie à 5 ans a été de 50.6% (268/530). Au total, 15,739 ganglions régionaux enlevés en cours d'opération (en moyenne 30 par pièce opératoire) ont été examinés: 16.0% renfermaient des métastases. Sur 339 malades avec cancer avancé ayant effracté les limites de l'organe, 74.9% avaient des métastases ganglionnaires; les survies à 5 ans ont été de 63.5% dans les cas sans métastase ganglionnaire et de 29.9% dans les cas avec métastase. Sur l'ensemble des survivants à 5 ans, 58.5% avaient des ganglions envahis. La résection presque totale d'au moins les premier et deuxième relais ganglionnaires drainant le cancer gastrique est un élément essentiel du traitement à visée curatrice. Pour les lésions des tiers supérieur et moyen de l'estomac qui envahissent la séreuse de la paroi gastrique postérieure, il faut réaliser une gastrectomie totale avec splénectomie et hémipancréatectomie gauche pour enlever en bloc les ganglions régionaux.

     

胃癌D2淋巴结清扫技术要点与实施

手术是胃癌综合治疗的重要措施.我国的胃癌患者就诊时多数已属于进展期,故推广实施规范化胃癌D2根治术意义重大.淋巴结清扫是D2胃癌根治术的核心和难点.本文重点探讨清扫No.4Sb、No.5、No.6、No.8a和No.9、No.10、No.11、No.12a、No.14和No.15组淋巴结的技术要点及其实施.     

Extended D3 lymphadenectomy in surgical treatment of stomach cancer

Results of 178 operations with extended D3 lymphadenectomy (study group) performed at the patients with stomach cancer are analyzed. Control groups consisted of 175 patients undergone operations with D2 lymphadenectomy, and 266 patients undergone surgery of typical extension. Study and control groups were similar according to prognostic factors. Indications for extended lymphadenectomy are formulated. It was demonstrated that short-term results in both group were equal. Safety of extended D3 lymphadenectomies wasalso confirmed. Extended D3 lymphadenectomies permitted to increase the respectability on 6.7%.